Objectives This study sought to evaluate in chronic kidney disease (CKD) prevalence and prognosis of true resistant hypertension (RH) (i.e., confirmed by ambulatory blood pressure ABP monitoring). ...Background In CKD, uncontrolled hypertension is a major risk factor, but no study has properly investigated the role of RH. Methods We prospectively studied 436 hypertensive CKD patients under nephrology care. Four groups were constituted by combining 24-h ABP with diagnosis of RH (office blood pressure ≥130/80 mm Hg, despite adherence to ≥3 full-dose antihypertensive drugs including a diuretic agent or ≥4 drugs): control (ABP <125/75 mm Hg without RH); pseudoresistance (ABP <125/75 mm Hg with RH); sustained hypertension (ABP ≥125/75 mm Hg without RH); and true resistance (ABP ≥125/75 mm Hg with RH). Endpoints of survival analysis were renal (end-stage renal disease or death) and cardiovascular events (fatal and nonfatal cardiovascular event). Results Age was 65 ± 14 years, men 58%, diabetes 36%, cardiovascular disease 30%, median proteinuria 0.24 (interquartile range 0.09 to 0.83) g/day, estimated glomerular filtration rate 43 ± 20 ml/min/1.73 m2 , office blood pressure 146 ± 19/82 ± 12 mm Hg, and 24-h ABP 129 ± 17/72 ± 10 mm Hg. True resistant patients were 22.9%, and pseudoresistant patients were 7.1%, whereas patients with sustained hypertension were 42.9%, and control subjects were 27.1%. Over 57 months of follow-up, 109 cardiovascular events and 165 renal events occurred. Cardiovascular risk (hazard ratio 95% confidence interval) was 1.24 (0.55 to 2.78) in pseudoresistance, 1.11 (0.67 to 1.84) in sustained hypertension, and 1.98 (1.14 to 3.43) in true resistance, compared with control subjects. Corresponding hazards for renal events were 1.18 (0.45 to 3.13), 2.14 (1.35 to 3.40), and 2.66 (1.62 to 4.37). Conclusions In CKD, pseudoresistance is not associated with an increased cardio-renal risk, and sustained hypertension predicts only renal outcome. True resistance is prevalent and identifies patients carrying the highest cardiovascular risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Whether the use of sevelamer rather than a calcium-containing phosphate binder improves cardiovascular (CV) survival in patients receiving dialysis remains to be elucidated. Study Design ...Open-label randomized controlled trial with parallel groups. Settings & Participants 466 incident hemodialysis patients recruited from 18 centers in Italy. Intervention Study participants were randomly assigned in a 1:1 fashion to receive either sevelamer or a calcium-containing phosphate binder (although not required by the protocol, all patients in this group received calcium carbonate) for 24 months. Outcomes All individuals were followed up until completion of 36 months of follow-up or censoring. CV death due to cardiac arrhythmias was regarded as the primary end point. Measurements Blind event adjudication. Results At baseline, patients allocated to sevelamer had higher serum phosphorus (mean, 5.6 ± 1.7 SD vs 4.8 ± 1.4 mg/dL) and C-reactive protein levels (mean, 8.8 ± 13.4 vs 5.9 ± 6.8 mg/dL) and lower coronary artery calcification scores (median, 19 IQR, 0-30 vs 30 IQR, 7-180). At study completion, serum phosphate levels were lower in the sevelamer arm (median dosages, 4,800 and 2,000 mg/d for sevelamer and calcium carbonate, respectively). After a mean follow-up of 28 ± 10 months, 128 deaths were recorded (29 and 88 due to cardiac arrhythmias and all-cause CV death). Sevelamer-treated patients experienced lower CV mortality due to cardiac arrhythmias compared with patients treated with calcium carbonate (HR, 0.06; 95% CI, 0.01-0.25; P < 0.001). Similar results were noted for all-cause CV mortality and all-cause mortality, but not for non-CV mortality. Adjustments for potential confounders did not affect results. Limitations Open-label design, higher baseline coronary artery calcification burden in calcium carbonate–treated patients, different mineral metabolism control in sevelamer-treated patients, overall lower than expected mortality. Conclusions These results show that sevelamer compared to a calcium-containing phosphate binder improves survival in a cohort of incident hemodialysis patients. However, the better outcomes in the sevelamer group may be due to better phosphate control rather than reduction in calcium load.
Background We investigated the effect of having clinic and/or ambulatory blood pressures (BPs) not at goal on cardiorenal risk in patients with non−dialysis-dependent chronic kidney disease (CKD). ...Study Design Multicenter prospective study. Setting & Participants 489 consecutive hypertensive patients with CKD (stages 1-5) with concomitant assessment of ambulatory and clinic BPs followed up in tertiary nephrology clinics. Predictors Achievement of goal for ambulatory (day- and night-time BPs < 135/85 and <120/70 mm Hg, respectively) and clinic (<140/90 mm Hg) BPs was used to create 4 BP groups: clinic and ambulatory BPs at goal (group 1), clinic BP above goal and ambulatory BP at goal (group 2), clinic BP at goal and ambulatory BP above goal (group 3), and clinic and ambulatory BPs above goal (group 4). Outcomes Composite cardiovascular event outcome (fatal and nonfatal myocardial infarction, congestive heart failure, stroke, revascularization, peripheral vascular disease, and nontraumatic amputation) and a composite renal outcome (maintenance dialysis therapy or death). Measurements Clinic and 24-hour ambulatory BPs. Results Mean age was 64.4 ± 14.2 (SD) years; 41% were women, and diabetes and previous cardiovascular disease were present in 36% and 30%, respectively. Groups 1-4 contained 16.8%, 22.1%, 14.5%, and 46.6%, respectively, of the overall number of participants. Median follow-up was 5.2 years. Compared to group 1, the adjusted risk of the composite cardiovascular outcome was higher in groups 3 (HR, 3.17; 95% CI, 1.50-6.69) and 4 (HR, 2.83; 95% CI, 1.50-5.34), but not in group 2 (HR, 1.55; 95% CI, 0.75-3.19). Similarly, the risk of the composite renal outcome was higher in groups 3 (HR, 3.59; 95% CI, 2.05-6.27) and 4 (HR, 2.96; 95% CI, 1.83-4.78), but not group 2 (HR, 1.24; 95% CI, 0.67-2.27). Sensitivity analyses confirmed that these results were independent from the thresholds used for defining groups. Limitations Only white patients were enrolled. Observational design does not allow for causality to be established. Conclusions In patients with treated CKD, clinic BP above goal and ambulatory BP at goal identify a low-risk condition, whereas clinic BP at goal and ambulatory BP above goal are associated with higher cardiorenal risk, similar to that observed in patients with both clinic and ambulatory BPs above goal.
Background Whether low-protein-diet (LPD) as opposed to moderate-protein-diet (MPD) regimens improve the long-term survival of patients with chronic kidney disease (CKD) or induce protein-caloric ...malnutrition is unknown. Study Design Intention-to-treat analysis of follow-up data from a randomized controlled trial. Setting & Participants 423 patients with CKD (stages 4-5) were randomly assigned between January 1999 and January 2003 and followed up until December 2006 or death. The first phase of follow up was from January 1999 to June 2004; additional follow-up was from July 2004 to December 2006. Intervention LPD versus MPD (protein intake, 0.55 vs 0.80 g/kg/d). Outcomes Protein-caloric malnutrition (defined as the occurrence of 1 of the following: loss of body weight > 5% in 1 month or 7.5% in 3 months or body mass index < 20 kg/m2 with serum albumin level < 3.2 g/dL and normal C-reactive protein level <0.5 mg/dL), dialysis, death, or the composite outcome of dialysis and death. Results Baseline mean age was 61 years, estimated glomerular filtration rate was 16 mL/min/1.73 m2 , proteinuria had protein excretion of 1.67 g/d, body mass index was 27.1 kg/m2 , protein intake was 0.95 g/kg/d, and there were 57% men. Duration of follow-up was 32 months (median, 30 months; 25th-75th percentiles, 21-39). Average protein intakes were 0.73 ± 0.04 g/kg/d for the LPD and 0.9 ± 0.06 g/kg/d for the MPD. 3 patients (0.7%) met criteria for protein-caloric malnutrition. 48 patients died (11%), 83 initiated dialysis therapy (20%), and 113 (27%) reached the composite outcome. In unadjusted Cox survival analyses, effects of the LPD on these outcomes were 1.01 (95% CI, 0.57-1.79), 0.96 (95% CI, 0.62-1.48), and 0.98 (95% CI, 0.68-1.42), respectively. Limitations Low event rates for dialysis therapy initiation and death. Conclusions Most patients, who were regularly followed up in CKD clinics, were acceptably adherent to the prescribed dietary protein intake restrictions; the LPD and MPD did not lead to protein wasting; and the LPD did not decrease the risk of death or dialysis therapy initiation compared with the MPD.
Chronic kidney disease (CKD) is increasingly common, and there is an increasing awareness that every strategy should be used to avoid complications of CKD. Restriction of dietary protein intake has ...been a relevant part of the management of CKD for more than 100 years, but even today, the principal goal of protein-restricted regimens is to decrease the accumulation of nitrogen waste products, hydrogen ions, phosphates, and inorganic ions while maintaining an adequate nutritional status to avoid secondary problems such as metabolic acidosis, bone disease, and insulin resistance, as well as proteinuria and deterioration of renal function. This supplement focuses on recent experimental and clinical findings related to an optimized dietary management of predialysis, dialysis, and transplanted patients as an important aspect of patient care. Nutritional treatment strategies are linked toward ameliorating metabolic and endocrine disturbances, improving/maintaining nutritional status, as well as delaying the renal replacement initiation and improving outcomes in CKD patients. A final consensus states that dietary manipulations should be considered as one of the main approaches in the management program of CKD patients and that a reasonable number of patients with moderate or severe CKD benefit from dietary protein/phosphorus restriction.
The prevention of malnutrition in patients with progressive chronic kidney disease (CKD) presents a challenge to nephrologists. We evaluated nutritional practice and routines, at a national level, ...related to the nutritional management of nondialyzed CKD patients.
A questionnaire-based survey (32 open and 9 multiple-choice questions) was used to assess the evaluation of nutritional status in nondialyzed CKD outpatients at baseline and during follow-up. Data were obtained for 230 Italian public nephrology centers (63% of the total number of Italian public nephrology centers).
There was a dedicated dietitian at only 19% of the centers. At baseline, body weight, body mass index, and serum albumin were determined in almost all centers, nutrient intakes and bioimpedance analysis in half the centers, and subjective global assessment and skinfold thickness in a small proportion of centers. During follow-up, the rate of assessments decreased by 8% for weight, 14% for nutrient intake, and 29% for subjective global assessment and skinfold thickness. Overall, the K/DOQI minimum criteria for nutritional assessment were fulfilled in only two thirds and half of the clinics at baseline and during follow-up, respectively. Multivariate analysis showed that the number of nutritional variables evaluated was significantly related to the size of the CKD clinic and the presence of a dietitian at baseline, but only with the presence of dietitian during follow-up. Daily urinary output was collected at 90% of the centers, but urea and sodium excretions were determined in only 59% and 57% of cases, respectively. The rate of assessment for urinary solutes during follow-up was higher at centers where a very low protein diet was prescribed.
The indications about nutritional assessment for CKD patients are poorly translated into practice patterns, especially with respect to the evaluation of nutrient intakes and additional but simple variables such as skinfold-thickness measurement and bioimpedance analysis. The presence of a dedicated dietitian appears to improve the quality of nutritional assessment in CKD.
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